Provider Demographics
NPI:1689351041
Name:PEGRAM, AMANDA JO (CNM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 E FARWELL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9829
Mailing Address - Country:US
Mailing Address - Phone:509-951-5257
Mailing Address - Fax:
Practice Address - Street 1:910 W 5TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2972
Practice Address - Country:US
Practice Address - Phone:509-755-5205
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACNM08720176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife